1. Diabetes Mellitus

2. What is DM? Definition: Type I vs Type II:
Where does insulin come from?
What does insulin do?

3. Epidemiology www.diabetes.org
Total: 23.6 million children and adults in the United States—7.8% of the population—have diabetes.
Diagnosed: 17.9 million people
Undiagnosed: 5.7 million people
Pre-diabetes: 57 million people
New Cases: 1.6 million new cases of diabetes are diagnosed in people aged 20 years and older each year.
90-95% of those are Type II
5-10% of those are Type I
Someone is diagnosed with Type I every 4 hours.
Increase incidence of Type II in the pediatric/adolescent population
$174 billion: Total costs of diagnosed diabetes in the United States in 2007
(2007 Data)

4. Diabetes Mellitus Signs & Symptoms1. 2. 3. 4. 5. 6. 7.
The brain needs sugar at a consistent amount, if doesn’t have it, you will have a decreased LOC

5. Type I DM Lack of Insulin
D/t destruction of the Beta cells in the pancreas
Destruction due to autoimmune process
Need to replace insulin via injection on a daily basis.

6. Type II DM Defect of insulin secretion or insulin resistance
Associated with obesity, hypertension, high cholesterol
Incr. in adolescence
Tx: diet, exercise, oral meds, insulin injections

7. Insulin Injections Give to fatty area Usually 2-4 times a day
Effects of injected insulin
Too much insulin=hypoglycemic
Too little insulin=hyperglycemic

8. Blood Glucose Levels Normal blood sugar 60/80 to 120 Monitoring
Only Insulin can be used to Tx Type I

9. Exercise & Type I DM
Muscle receives energy from stored muscle glycogen & fatty acids. Type I diabetics “lack” insulin, thus don’t have the ability for muscles to take up glucose from the blood. (external dose of insulin required)
Pt must anticipate glucose needs! BALANCE!!!
Must consider when they are going to exercise in relationship to meals and injections. Need less insulin when exercising, due to efficiency.
Types of activity, intensity & duration

10. Exercise & DM Hypoglycemia – too much insulin
Blood sugar < 60 mg/dl
Symptoms of LOW blood sugar:

11. Exercise & DM
Tx:
Severe reaction: unconscious victim

12. Delayed Hypoglycemia Exercise increases the utilization of glucose
Can last up to 72 hours.

13. Preventing Hypoglycemia
Anticipating energy needs:
Check blood sugar prior, during & after exercise.
Always have sugar available
Wear an ID bracelet
Prevent dehydration

14. Insulin Pump Continuous insulin administration
Know how to turn it off!!!

15. Exercise & Type II DM
Associated c obesity, hyperinsulinemia & hyperlipidemia
Key management in these people is diet & exercise!!
Increases insulin sensitivity

16. Exercise and Type II DM
Pts may be at higher risk of hypoglycemia during exercise if they are on certain medications, (sulfonlyureas, etc) or if on insulin.
Check blood glucose prior to exercise and have source of sugar available.

17. DM, Complications & Exercise
The right balance of Insulin:
Individual error in prediction of needs in comparison of amt of exercise
Injected insulin may be absorbed into the bloodstream more rapidly during exercise & a pump can’t adjust to the decreased needs of insulin c exercise as quickly as the body. (hypoglycemic)
Not injecting enough (hyperglycemic)
Need to replenish calories after a workout to replace glycogen levels to normal

18. Reasons they should Exercise
Beneficial in maintaining ideal body weight and avoiding obesity in the Type I pt.
Main therapy in the Type II pt in assisting wt loss
Increase insulin sensitivity
May decrease CV risk factors such as hyperlipidemia & hypertension
Improve sense of well being.

19. Complications www.diabetes.org
Long term effects usually occur after having the disease for >10 yrs
Retinopathy
Blindness
• Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years. • Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.
Nephropathy
Kidney disease
• Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in • In 2005, 46,739 people with diabetes began treatment for end-stage kidney disease in the United States and Puerto Rico. • In 2005, a total of 178,689 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney transplant in the United States and Puerto Rico.
Neuropathy
Nervous system disease (Neuropathy)
• About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage.

20. Complications www.diabetes.org
Heart disease and stroke
• In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older. • In 2004, stroke was noted on 16% of diabetes-related death certificates among people aged 65 years or older. • Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. • The risk for stroke is 2 to 4 times higher among people with diabetes.
High blood pressure
• In 2003–2004, 75% of adults with self-reported diabetes had blood pressure greater than or equal to 130/80 mmHg, or used prescription medications for hypertension.

21. Complications www.diabetes.org
Morbidity and Mortality
Deaths
Diabetes was the seventh leading cause of death listed on U.S. death certificates in This ranking is based on the 72,507 death certificates in 2006 in which diabetes was listed as the underlying cause of death. According to death certificate reports, diabetes contributed to a total of 233,619 deaths in 2005, the latest year for which data on contributing causes of death are available.
Amputation
• More than 60% of nontraumatic lower-limb amputations occur in people with diabetes. • In 2004, about 71,000 nontraumatic lower-limb amputations were performed in people with diabetes.
Strength training should be avoided in pts who have had diabetes for more than 10 years -hypertensive tendencies cause problems.

22. For the ATC Items to have available: Glucometer Gel Tablets
Glucagon injection?
Know who is diabetic on your teams and know how well they are controlling it!
Treat ALL acute diabetic illness c glucose!

23. For the ATC Drug Interactions to be aware of:
Alcohol: NEVER…causes hypoglycemia
Anabolic Steroids: same
Birth control pills: reduces the effects of insulin

24. Glucometer Use Frequency: ~ 4x day Proper use Supplies
Control test strip
Clean skin
Puncture
Wipe way 1st blood
Blood on test strip and wait!

25. Hypoglycemia
S/S:
Tx:
Don’t forget late onset-hypoglycemia! Monitor in the middle of the night c increase in activity the day before.

26. Hyperglycemia S/S: Tx:
D/T lack of sugar in cells, body turns to fat for energy source. By-product is Ketones. Turns blood acidic. Person will drink a lot of water to offset polyuria….leads to diabetic ketoacidosis.

27. How can you tell them apart?
1: Onset
2. Skin
3. Breath

28. TREATMENT OF ALL DIABETIC EMERGENCIES
GIVE GLUCOSE TO EVERYONE!
Hypoglycemic – get needed sugar into blood stream and to the brain.
Hyperglycemic – the extra dose of sugar will not cause damage in the short time before you reach the ER.

29. RED FLAGS for DM Sweating Palpitations Hunger Tremors
Confusion/altered LOC HA
Nausea
Fatigue
Slurred speech
Inappropriate behavior
Decrease coordination

30. Information sources American Diabetes Association 1-800-DIABETES
1-800-DIABETES